APPENDIX 3

APPENDIX 3
Info Sheet on Trauma-Informed Engagement Skills

Skills & Strategies for Engagement—Linking Motivational Interviewing

and Trauma-Informed Practice
Motivational Interviewing (MI) [71] is an evidence-based communication style shown to improve
engagement, retention, and treatment outcomes across numerous health areas including MHSU [72,
73]. The efficacy of the approach is also noted for working with youth [74, 75] and ethnic minority
groups [72]. There are many parallels between the principles of MI and trauma-informed practice,
including emphasis on collaboration, and respect for autonomy and empowerment. The value of
integrating the approaches is gaining attention [76-78].

There are a number of skills and strategies that can be drawn from MI to build and maintain
engagement and can be used throughout interactions with individuals and families: open-ended
questions, affirmations, reflective listening and summaries (also known by the acronym OARS);
opening statements; and, agenda setting.

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1. OARS
Open-Ended Questions
Open-ended questions cannot be answered with a yes or no, or simple one word answers. They create
the space for people to tell their story in their own words, thereby influencing the direction of the
conversation and supporting engagement.

Practice Examples:
“What are you already doing to take care of yourself?”

“What concerns you most about your health, if anything?”

“What have you noticed helps you when you are really stressed?”

“What do you need to get out of this group to make it worth your time?”

“You’ve mentioned other similar programs you’ve attended in the past. What needs to be
different this time to make it worth your while?”

“How can we support you to feel safe in this program?”

“How have you managed to get through other difficult times in your life?”

There may be situations when open-questions feel too broad or overwhelming for some (e.g., when
working with youth, individuals with cognitive challenges, language barriers). One variation is to offer
multiple choice answers so that the individual still has options, and the response is contained [74].

Note: Closed-ended questions that are answered with yes/no (“Do you have children?”) or one word
(“How many children do you have?”) are sometimes necessary. Generally speaking, the practitioner
uses more open-ended questions to engage the individual in the conversation and avoids asking too
many questions in a row, rendering the individual passive in the interaction.

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Affirmations
Genuine, specific, and relevant affirmations build self-efficacy and offer a compassionate mirror for
self-reflection. Affirmations acknowledge effort and strength; offer appreciation and understanding;
and recognize success—all important components of trauma-informed practice. Keep in mind, this may
be a very different experience for individuals with a history of trauma. It may take some time for them
to trust that your responses are genuine. It is important to share affirmations in a tone that conveys
empathy and support.

Practice Examples:
“No matter what, you don’t give up.”

“Your children are your first priority.”

“You have been through so much in your life and are doing everything you can to make sure
that things are different for the next generation.”

“You made it here today, in spite of all the chaos at home this morning.”

“I can see you practicing your grounding skills, even as we are talking.”

“You are doing really well at school even though there is a lot you are dealing with right now.”

Reflective Listening
Reflective listening is an essential skill for engaging and maintaining connection. Reflections help
individuals to feel heard and valued. For many, this may be a new experience. Practitioners listen for
the meaning and essence of what they believe they have heard the individual say and offer back a
statement of understanding [79]. There is no wrong answer, and you have immediate feedback in terms
of what the individual says next and whether the conversation keeps going. Ultimately, you want the
individual to keep talking.

Reflective listening can also be quite helpful with someone who is non-verbal. Perhaps they don’t
want to be there or they are not sure what is expected of them, what to say, or what is safe to say.
Responding with a reflective statement is less likely to draw out resistance [71]. A question requires a
response and asking too many questions can create a power-dynamic whereby the practitioner asks the
questions and the individual seeking treatment feels they have to respond.

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Practice Examples:
Youth: You’re the third person I’ve had to talk to since I got here…I am so sick of answering
everyone’s questions.
Practitioner: It is really frustrating to have to keep retelling your story. You’re wondering if
I can be helpful, or if I will just pass you on to the next person.

Woman: I don’t want to feel this way, but I just have no idea how to make the pain stop.
Practitioner: Nothing you have tried has worked so far…and at the same time you know
somehow that things can be different.

Man: I know I need to go back to work, but every time I think about getting in the car and
driving, I get knots in my stomach.
Practitioner: You are wondering how you are going to do it.

Summaries
In trauma-informed practice, summaries are a helpful way to link ideas, reflect mixed feelings about
change, clarify understanding, focus and contain the conversation, and facilitate transition to next steps.

Practice Example:
“Let me make sure I understand what you have told me so far…it was a big step for you to
come in and speak with someone today. You have been struggling for a while and, for the most
part, have managed to take care of things on your own, go to work, manage the household…
and then this big change happened when you lost your job. That’s thrown you back into old
familiar patterns...you’re noticing that you feel on edge all the time; quick to anger; and there
are days when you can’t get out of bed. You’re starting to isolate yourself again. It’s like the
ways you knew how to stop your mind from racing are gone and things are spinning out of
control. This is the first time you’ve started to talk about all of this out loud. You’ve reached a
point where you realize that you can’t do this on your own and need some support and you’re
just not sure what type of support you need…What did I miss, if anything?”

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2. OPENING STATEMENT
The opening statement sets the tone for the conversation. The purpose of the opening statement is to
begin with role definitions and to state how this interaction may be different from other conversations
they have had, including with other practitioners. The key is to convey that you will support the
individual in the changes they would like to make, not to tell them what they should do [74]. Despite
the best intentions of practitioners, individuals may expect to be lectured and shamed about their
perceived inadequacies, substance use, mental health concerns, etc. They may walk in the door, having
already rehearsed what to say in response to expected questions, and are ready to tell you all the
reasons why the program or service will not work for them. Explicitly letting the individual know
that you are there to support them and figure out together the most helpful way forward conveys
collaboration and safety, and honours autonomy.

Practice Example:
“Thank you for taking the time to speak with me. I appreciate it’s not easy coming to a
new program and speaking with someone you don’t know [introduce self & role, review
confidentiality, how much time you have etc.]…Our conversation may be different than those
you have had with other people you have spoken with. Rather than telling you what to change
and how to fix it, I’d like to find out how I can be helpful and support you in the decisions
you choose.”

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3. AGENDA SETTING
Agenda setting can be done in different ways, depending on how much time you have, your role, and
context. Ultimately, the goal is to collaboratively find the focus of the conversation and get a sense
of what is most important to the individual at this time [80]. It is a strategy that can be returned to
throughout your work together, to start the conversation, find focus, or develop a plan. It can also be
adapted for a group context.

One way to begin is by using a bubble sheet or agenda setting sheet (see pg. 49 for a blank copy of
the Agenda Setting Worksheet), listing some of the areas that you have conversations about with all
individuals who come to your service. By limiting the conversation to 5-7 topics, you minimize the risk
of overwhelming the individual. Indicating the key areas also conveys the topics you know something
about, establishes the parameters of your role, normalizes the types of conversations you have, and
opens up the agenda to include a variety of areas related to MHSU. Keep in mind, it is important to
focus on areas that individuals can control [76] and pay attention to the language used. Leave some
circles blank for other topics the individual may want to add.

Practice Example:
“Let’s take a look at this sheet together. These are some topics that other people have wanted
to talk about and some of the areas where our program can offer support. For example,
housing, mental health, employment, relationships, parenting support, as well as substance
use…and there may be something else that is more important to you right now that you would
like to add… [individual responds]…So, looking at these topics, which would be the most
helpful to start with today?”

Adaptations
As with any strategy, you want to adapt the approach depending on who you are working with by
considering diversity, age, developmental stage, and cognitive abilities [74, 81, 82]. For example, using
images that are age or culturally appropriate (instead of words) and reducing the number of topics
and/or using visual aids when working with someone with cognitive challenges.

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Agenda Setting When Time is Limited

If your time is limited and you do not have the opportunity to do more comprehensive agenda setting,
consider asking permission before moving too quickly into information. You can also use an open-
ended question to draw out the individual’s perspective about how things are going for them.

Practice Example:
“We only have a few minutes today, and I wanted to follow-up on the conversation we started
last time about your troubles sleeping and the nightmares you have been having, wondering
where that conversation may have left you. Would that be okay?... [individual responds]…
What have you noticed since the last time we spoke?”

Relationships Housing

Child/ Mental Employment

Parenting Health

Substance Use What Else

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Appendix 3a – Agenda Setting

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